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Confidential

Retirement Planning Review

Questionnaire

 

 

 

¨ Personal Information ¨

 

Name_______________________________ Address_________________________________________

City__________________________________  State_______  Zip Code__________________________

Home Phone Number_______________________  Business Phone Number_______________________

 

Personal E-Mail Address__________________________

Participant’s Date of Birth_________________________

Beneficiary’s Date of Birth (0 if none)_________________________   Spousal   Non-Spousal

Spouse’s Name (if applicable) ________________

 

Estimated Date of Retirement or Separation from Service _________________ 

 
 
 

 

 


¨ Retirement Information ¨

 

Amount of Distribution:

 

1) Pension Lump Sum (if applicable) $______________________

2) Monthly Pension $______________________

3) Savings Plan 401(k) $__________________________   Contribution % ___________

            After-Tax Contribution Amount (if any) $______________________

4) Total Rollover $______________________

 

Age You Would Like Withdrawals to Begin____________

 

 

 

 

 

***Anticipated after tax monthly income

      needs at retirement from all sources $_________________________

 

 

 

 

¨ Employee Information ¨

 

Position__________________________                   Annual Salary______________________________

Years with Company_______________

 

¨ Outside Capital and Income ¨

 

                                                            Total Value                            Notes

Stock Portfolio Value                         $____________________            ______________________________

Liquid Investments                             $____________________            ______________________________

(Savings, Money Market, Cd’s)

Current IRA Accounts                        $____________________            ______________________________

Tax Free Investments                         $____________________            ______________________________

(Municipal Bonds)

Others                                                 $____________________            ______________________________

(Mutual Funds, etc.)

 

¨ Other Income ¨

 

Social Security                                               $____________ /yr.   at age _______

Employment After Retirement                      $____________ /yr.   from __________ to __________   

Spouse Employment After Retirement          $____________ /yr.   from __________ to __________

Other Expected Income                                  $____________ /yr.   from __________ to __________

                                                                        Source_________________

                                                                        $____________ /yr.   from __________ to __________

                                                                        Source_________________

Spouse’s Retirement Benefits                                    $____________/yr.    pension at age _______

                                                                        $__________________   lump sum distribution

 

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